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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 11/12/2021
Date Signed: 11/12/2021 04:33:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CEDARBROOK MEMORY CARE COMMUNITYFACILITY NUMBER:
107206749
ADMINISTRATOR:LISA POOLE-JOHNSONFACILITY TYPE:
740
ADDRESS:1425 E. NEES AVETELEPHONE:
(559) 412-2299
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:68CENSUS: 49DATE:
11/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Exexcutive Director, Sarah DennisTIME COMPLETED:
01:10 PM
NARRATIVE
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On 11/12/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Case Management – Incident visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator, LPA met with Executive Director, Sarah Dennis.

The purpose of today’s visit is to follow up on incidents that were reported to the Fresno CCL office.

It was reported that on 08/24/2021, facility staff went to R1’s apartment to administer medication. Upon arrival, staff was unable to locate resident. Facility immediately initiated search protocols at approximately 8:45PM. The Police Department (PD) and R1’s responsible party was notified. R1’s family located R1 near Fresno State at approximately 1:35AM. R1 was transported back to the facility by family and returned to the facility at approximately 1:45AM.

Based on today’s inspection, a deficiency is being cited in accordance with the California Code of Regulations, Title 22 see attached 809D. An immediate civil penalty is being assessed in the amount of $500 for the absence of supervision.

An exit interview was conducted. A plan of correction was reviewed and developed with Executive Director. As a COVID-19 precautionary measure, copy of this report and appeal rights will be provided to Executive Director via email and an electronic read receipt confirms receiving this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CEDARBROOK MEMORY CARE COMMUNITY
FACILITY NUMBER: 107206749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2021
Section Cited

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§1569.312 Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by:
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Based on record review, Licensee did not ensure all residents were provided care and supervision when on 8/24/2021, facility staff were unable to locate R1 in R1’s bedroom. R1 was located outside of the facility near Fresno State.
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Licensee stated staff have been trained on Elopement protocols. Documentation of training topics and attendance will be submitted to the Fresno CCL office 11/15/2021.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021
LIC809 (FAS) - (06/04)
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